Valentina Pinelli

Pleural Fluid Cytological Yield and Visceral Pleural Invasion in Patients with Epithelioid Malignant Pleural Mesothelioma

Introduction: Malignant pleural mesothelioma (MPM) is an aggressive malignancy arising from mesothelial cells lining the pleura. Most commonly, it presents as a unilateral pleural effusion. MPM usually develops on the parietal pleural surface and later spreads to the visceral pleura. Visceral pleural involvement entails a more advanced disease stage and is therefore an important prognostic factor. Pleural fluid (PF) cytology is often the first diagnostic test, but the sensitivity in the literature varies from 4 to 77%. However, no data are available for the diagnostic yield of cytological PF analysis with regard to the visceral pleural involvement. The aim of this study is to assess whether PF cytological yield is related to the extent and pattern of visceral pleural invasion, as assessed by thoracoscopy. Methods: Medical records of all patients who underwent thoracoscopy for suspicion of malignant pleural effusion from two hospitals were reviewed. Patients were selected if they initially underwent a diagnostic thoracentesis before thoracoscopy, if visceral pleural appearance during thoracoscopy was clearly documented, and MPM confirmed on pleural tissue biopsy. Results: Seventy-five patients were selected. Forty-five patients had a positive PF cytology on thoracentesis, while 30 had a negative PF cytology. Thoracoscopy showed parietal pleural invasion in all subjects. Interestingly, 82% of patients with positive PF cytology on thoracentesis had visceral pleural involvement, whereas only 30% of those with negative PF cytology had visceral pleural invasion. The pattern of visceral pleural invasion consisted of pleural masses, nodules, or pleural thickening. A multivariate regression identified visceral pleural invasion (p < 0.001) as the only independent factor predicting the positivity of cytology on pleural effusion. Conclusion: In epithelioid MPM, PF cytological yield was significantly higher in patients with visceral pleural invasion assessed by thoracoscopy. Positive PF cytology is associated with a more advanced disease.

Minithoracoscopy: a complementary technique for medical thoracoscopy.

Minithoracoscopy, currently defined as thoracoscopy with instruments of a diameter between 2 and 5 mm, is part of the general evolution of endoscopy towards mini-invasiveness. Its most relevant indications in the field of medical thoracoscopy are small effusions, pleural effusions in patients with narrow intercostal spaces and suspected tuberculous pleurisy in areas of low incidence of tuberculosis. In general, it increases the versatility of medical thoracoscopy.

Effects of combined therapies on the survival of pleural mesothelioma patients treated in Brescia, 1982-2006

AIMS AND BACKGROUND During the 1990s, the traditional unimodal treatments (surgery, radiotherapy, chemotherapy, immunotherapy) for malignant pleural mesothelioma started to be combined in bimodal or multimodal strategies. However, recent population-based analyses of the survival of patients with malignant pleural mesothelioma indicate that even these treatments have not led to significant improvements in prognosis, which remains very poor. The present study assessed the survival of patients given combined treatments and multimodal therapies in a specialized hospital department. METHODS The study population comprised 530 patients diagnosed with malignant pleural mesothelioma from 1982 to 2006: 343 of them were residents in the province of Brescia (Lombardy, Northern Italy) and 187 were residents outside the province, with a follow-up to 31 December 2009. Kaplan-Meier survival analyses and Cox proportional risks model were used to test sex, age at diagnosis, histological type and treatments, as prognostic factors. RESULTS The estimated median survival for the whole group of patients was 317 days (257 for residents and 398 for non-residents), and respectively 310 and 340 days in the groups diagnosed in the periods 1982-2000 and 2001-2006. Multivariate analysis confirmed that the prognosis was better for younger patients and cases of epithelioid type malignant pleural mesothelioma, whereas for patients receiving any single treatment the prognosis was not significantly better than for those given palliative care alone. However, patients receiving combined treatments or the multimodality approach had significantly longer median survival and the relative risk of death was respectively 0.57 and 0.61 compared to untreated patients (or those only given symptomatic therapy). CONCLUSIONS This is the first study in Italy to assess the effectiveness of different treatment approaches in a significant number of patients treated in one hospital. Further studies are needed to confirm the improvement in prognosis - even if modest--on larger numbers of patients and taking into account the different stages of the disease.

Population genetic screening for alpha1-antitrypsin deficiency in a high-prevalence area.

Background: Current guidelines for α1-antitrypsin deficiency (AATD) state that adult population screening should only be done in high-risk areas. Up-to-date genetic methods are always recommended. Objectives: To determine the prevalence of AATD in a suspected high-risk area by population screening, applying new genetic analyses and comparing the prevalence of liver and lung abnormalities in subjects with or without AATD. Methods: Adult residents of Pezzaze, a village in an Italian alpine valley, voluntarily participated in the screening, and were examined for: nephelometric α1-antitrypsin (AAT) serum level, DNA analysis (mutagenic polymerase chain reaction and restriction fragment length polymorphism tests for Z and S AATD causative mutations, and denaturing high-performance liquid chromatography and/or direct gene sequencing if needed), serum aspartate and alanine transaminases, a respiratory questionnaire and the Medical Research Council dyspnea index scale. The prevalence of AATD was compared with that expected in Italy (Hardy-Weinberg equilibrium), and transaminases and the prevalence of respiratory symptoms were compared between study groups. Results: Of 1,353 residents, 817 (60.4%) participated; 67 (8.2%) had low AAT serum levels (<90 mg/dl); 118 were carriers of AATD-associated alleles, 4 (0.5%) homozygotes or compound heterozygotes (1 Z, 1 S, 2 ZPbrescia), 114 (14%) heterozygotes (46 Z, 52 S, 9 Pbrescia, 4 Mwurzburg, 2 I, 1 Plowell). The prevalence and frequency of all AATD-related alleles was higher than expected for Italy (p < 0.001). There were no differences in symptoms of respiratory disease and transaminases between individuals with normal and low serum AAT. Conclusion: The screening design is one of the main strengths of this study. The large number of mostly asymptomatic individuals with AATD identified suggests that in high-risk areas adult population screening programs employing the latest genetic methods are feasible. Early recognition of individuals at risk means primary or secondary prevention measures can be taken.

Role of respiratory-triggered diffusion-weighted MRI in the assessment of pleural disease

OBJECTIVE: To evaluate the correlation between apparent diffusion coefficient (ADC) values and histopathological features in a cohort of patients with suspected malignant pleural disease. METHODS: We evaluated 56 consecutive patients undergoing a chest MRI examination for clinical suspicion of malignant pleural disease; all patients underwent thoracoscopic biopsy for histological assessment. All MRI examinations were performed with a 1.5-T scanner using a dedicated protocol, including a respiratory-triggered diffusion-weighted sequence with three b-values (0, 100 and 750). The ADC values were calculated, and a statistical analysis was performed. RESULTS: The average ADC value in non-neoplastic pleural disease (NNPD) resulted in 1.84 ± 0.37 × 10-3 mm2 s-1, whereas we obtained an average value of 0.96 ± 0.19 × 10-3 mm2 s-1 in epitheliod, of 0.76 ± 0.33 × 10-3 mm2 s-1 in biphasic and of 0.67 ± 0.2 × 10-3 mm2 s-1 in sarcomatoid pleural mesotheliomas. Histology revealed the presence of malignant pleural mesothelioma (MPM) in 44 patients, chronic pleuritis in 8 patients and atypical mesothelial hyperplasia in 4 patients. Statistical analysis showed a significant difference between NNPD and MPM (p < 0.001) and between epithelioid and sarcomatoid MPM subtypes (p = 0.0004), whereas biphasic MPMs showed a wide range of overlapping with the other groups. CONCLUSION: We observed a statistically significant difference between NNPD, epitheliod and sarcomatoid subtypes of MPM regarding ADC values. ADVANCES IN KNOWLEDGE: Our study confirmed previous data regarding distribution of ADC values in pleural disease using a respiratory-triggered diffusion-weighted technique that allowed us to minimize motion artefacts and to reduct acquisition time.

Contents Vol. 89, 2015

440 Joint Annual Meeting of the Schweizerische Gesellschaft für Pneumologie / Société Suisse de Pneumologie Schweizerische Gesellschaft für Pädiatrische Pneumologie / Société Suisse de Pneumologie Pédiatrique Schweizerische Gesellschaft für Thoraxchirurgie / Société Suisse de Chirurgie Thoracique Schweizerische Gesellschaft für Pulmonale Hypertonie / Société Suisse sur l’Hypertension Pulmonaire 16–17 April 2015, Lugano